Idealism vs Realism: Balancing the Scales in O&P Practice

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By Judith Philipps Otto

We all want to make a difference in this world; most of us want to leave it a better place than we found it. In our youth, filled with confidence and high ideals, fired with enthusiasm, we face a life of limitless potential.

Unfortunately, with each passing moment, and with each of the hundreds of choices we make every day, we limit ourselves to a narrower and narrower path of opportunity and accomplishment.

And somewhere during this process, our aging ideals are subtly altered by reality. The "what could be" becomes "what is"; the "what could happen" becomes "what did"!

So where are they now, those lofty ideals with which many came to the O&P field? Has the hard reality of Medicare cost-cutting, diminishing reimbursements, encroachment by therapists and manufacturers, the breakdown of negotiated rulemaking, internal bickering over American Board for Certification in Orthotics & Prosthetics (ABC) and Board for Orthotist/Prosthetist Certification (BOC) unification and more, turned us into cynics? What is it that keeps O&P and other healthcare providers in their beleaguered fields?

Justin Foster, CPO, was fresh out of school and new to the profession when he raised questions on OANDP-L, questioning, among other things, how O&P practitioners could justify the high prices and accusing them of becoming fat cats by feeding on patient needs.

Justin Foster, CPO
Justin Foster, CPO

Things have changed a lot since then. Foster admits that, although he feels more motivated each day, the word idealism' has taken on new meaning.

"I was very vocal about what I saw as serious faults in our profession from the day I entered," he recalls. "What I have found since publicly airing those concerns is a group of people that are more dedicated than I had ever imagined to making a real difference in the lives of people. I have been truly inspired by the time and effort expended by members of our field in the pursuit of better quality prosthetic and orthotic care.

"Several high-stature individuals took the time to guide me--some with a firmer hand!--through what was a difficult time in my young career, learning how to balance the ugly' side of business with the ultimate goal of healthcare. As a resident fresh out of school, it is not immediately apparent why a Flex-Foot® is so expensive, or why you can't just waive a Medicare deductible.  

"Motivation comes from the challenge of continuing to provide quality prosthetic and orthotic care in spite of what is against us, almost as if a call-to-arms is being broadcast! My new idealism' is not to give away the farm, but rather to fit ALL of the pieces together to be able make an AFO or prosthesis each time it is needed by a member of our community."

Jan Stokosa, CP, Stokosa Prosthetic Clinic, Okemos, Michigan, notes that he feels as motivated and idealistic today as when he first entered the profession--probably more so.

Jan Stokosa, CP
Jan Stokosa, CP

"I think if a person gets into this field with the intent to truly help somebody get back to their life, I don't see how one could ever get exhausted in that attempt."

Stokosa uses a formula to assess a new patient: 

  • Objective physical capability;
  • Quality and level of amputation;
  • Relevant technology;
  • Prosthetist's ability and willingness to innovate; and
  • Amputee aspirations and will.

"Many prosthetists today have very little talent using their hands," Stokosa says. "They can use a computer, and they can design a prosthesis. But in complex cases, that utility becomes less useful. You've got to be able to work with your hands, and you've got to be able to innovate. If we can't solve a patient's issues via conventional methods, then we come up with something; we may have to make or redesign a component.

"So with this kind of challenge, and with all the new technology, I don't see any prosthetist's senses being dulled with respect to the ideal of allowing the person to get back to the most comfortable, stable, functional life they can. With so many options now available, no one really has the ability to predict what this person is going to be successful with. All the suspension, all the interface materials, all the foot, ankle, knee, hand, wrist, elbow components--we simply don't know. So it requires us to be very sharp, evaluate and test each person, and try to come up with the best possible solution.

"I was using wood when I started in prosthetics. I saw plastics appear in the 50s. The changes--the continuing progress--is fascinating and exciting. I think anybody who has lost their sense of idealism maybe is not meant to be in this field."

Michael Davidson, CPO, clinical manager at Loma Linda University Orthopaedic & Rehabilitation Institute, Loma Linda, California, says he feels even more motivated and idealistic now than when he began his work in the field 16 years ago. "Why? --I don't know why," he says. "Possibly because I've had several patients that have done incredible things physically, and they have challenged my definition of what disabled' is. When somebody with a missing limb or paralysis can go compete in a competitive sporting event that I have never dreamed of doing, it makes me really question my sore knee and the excuses that I can come up with!

"Helping people with physical disabilities has really challenged my thinking since I've gotten into the field. So in a way, some of the patients that I help, in turn, also help me confront my challenges. When you think about it, we all have challenges in some form, shape, or another, and we all have to confront them&Confronting our challenges now helps prepare ourselves for bad things that happen in life, and therefore makes us better as people. So in a sense, I make my patients whole, and in turn they make me whole."

Mike Allen, CPO, FAAOP
Mike Allen, CPO, FAAOP

Michael J. Allen, CPO, FAAOP, Allen O&P Inc., Midland, Texas, is a second-generation practitioner in a 50-year-old practice, but admits that he feels as idealistic now as he ever has. "Choosing O&P as a profession was a choice made for a reason, and the challenges faced today to provide a high level of care haven't taken away the motivation--haven't affected that at all. It's still fun to work with people.

"We're excited about our company's 50th anniversary celebration this year, and we have many activities planned for the area children and disabled community. I work with patients today that I sat on the floor and played cars with many years ago. The sense of continuity is very rewarding: Two years ago, I replaced bilateral KAFOs for a post-polio patient who literally changed my diapers. That's one of the joys of being second-generation."

Jim DeWees, CP, BOCP, Prosthetic Center of Indiana at Bloomington, has had his own rocky road to travel. A 39-year-old six-year amputee, DeWees had a series of painful disappointments as a prosthetic patient which prompted him to switch careers from pathology to prosthetics so he could make his own legs as well as help others.

After completing the Cal State O&P program, he got a job with a major O&P employer--and some unpleasant first-hand experience with being required to sell the cheapest possible components for the highest possible markup and to limit himself to the same uncomfortable and inappropriate items as an example to his patients.

DeWees switched jobs, but uncovered a situation where again, sales and profits were more important than patient care, and salary and bonuses were based on how much money he could generate.

"I was on the verge of switching back to a career in pathology, when I decided to give prosthetics another chance, and opened my own practice in Indiana about 15 months ago. It has been a lot of work, but very rewarding and very successful.

"In January and February, I was really burned out and needed to do something to remind me why I got into this field in the first place. So I started a nonprofit organization to make prosthetic limbs for amputees in the Dominican Republic, where I had lived from 1984 to 1986, when I was 1921 years old. I speak Spanish fluently and really love that country. There are so many amputees there, being treated by 1940s1950s standards. If a bone is broken and cannot be set and cast easily, they amputate the limb.

"So while I was there, I also met with a couple of men that have an O&P practice there, and I made six limbs with materials they had, and also brought five more casts back to my office in Indiana to make the limbs here. I am going back to fit these five limbs, and I will cast another 12 patients there, and bring the casts back here, make them, return a few months later, etc. This will be an ongoing adventure.

"This trip was so rewarding, and it was exactly what I needed to give me that boost again to remind me why I am working in this field. These people are so grateful and happy to get anything to help them live a little better life.

"Being an amputee makes this profession more important to me; it is a passion of mine, and not just a job. I know there are many non-amputee prosthetists who also have a passion for it. But there are many prosthetists--amputee and non-amputee--that have lost sight of the patient and can only see the dollar signs now. That really bothers me. But as long as there is a prosthetist in the area that is passionate about quality and service, he will hopefully take all the business away eventually from the greedy practitioners/companies."

What helps you maintain focus in the face of abundant negatives?

Alberto Esquenazi, MD
Alberto Esquenazi, MD

Foster: "As long as people keep coming to us for assistance in meeting their goals, we are tasked with innovation, compassion, and completion of this work. Part of my fun time' each day is coming up with creative ideas to solve not only clinical concerns, but business and logistical problems as well. Nothing feels better than a job well done! That feeling is what keeps me coming back for more challenges in all aspects of what we do."

Alberto Esquenazi, MD, chair, Department of Physical Medicine & Rehabilitation at Albert Einstein and MossRehab, and director, Amputee Rehabilitation Center, MossRehab, Philadelphia, Pennsylvania, has been involved in patient care for more than 20 years. What keeps Esquenazi focused? "The patients--knowing that you can do something for them, and that you are really providing them with an opportunity to return to the kind of life that they deserve. You may have hundreds of obligations throughout the day, and all it takes is one patient saying, Thank you very much. You really made a difference.' In the end, that is really what drives you."

Charles Levy, MD
Charles Levy, MD

Charles Levy, MD, chief, Physical Medicine & Rehabilitation, North Florida/South Georgia Veterans Health System: "I think this boils down to whether you have made the decision to try to do good in the world. If you have decided that part of your existence is to be an advocate for those in need, then you simply try to pursue that in your daily life.

"It's not really based on whether you are always successful or whether you get nice fuzzy feelings back. You pursue it because you're dedicated to betterment in the world, and this is how you express that dedication. If you're not--if you're pursuing this because you think it would be good for your business, that's not necessarily a bad thing, but I don't think that's a very durable motive--because maybe you'll decide you can make money elsewhere&"

Allen: "I believe a lot of what keeps me focused is the changing technology and the opportunities that it allows us to enhance patient care."

Positive and Negative Influences

Foster: "I have had the most difficulty adjusting to the fact that without money involved, there would be less innovation, less invention, and less success in our outcomes. It is certainly not unique to P&O; rather P&O is captive to this system as a whole. Some of what we do on a regular basis lends particularly well to questions of cost vs. efficacy, but because of the relatively small number of consumers of our products, it is a necessary evil.

"Everyone in every business is facing rising costs in this country; the challenge is to remain viable while putting out a safe and effective product. On the positive side, healthcare can't exist without helping people. It is what we often take for granted, and what many of us first and foremost want to do with our lives!"

Esquenazi: "Reimbursement is definitely a negative factor--I think it's not so much the reimbursement itself but the way we have deployed the resources that we have. I don't know that we have a clear guidance on the best way to deploy those resources. And not having the freedom to utilize your budget in the most intelligent way for your patient is something that is at times frustrating.

"I remember years back when the managed care company told me I could prescribe one device for a patient--for his lifetime. Get whatever you want for him--we'll pay for it--but it's one for the lifetime.' It was ridiculous--this is a 17-year-old kid who was hurt in an accident and lost his leg. It's like telling someone they have a chance to get one pair of shoes for the rest of their life. You pick the best shoes you can--but they're not going to last--and you're eventually going to have to do something about that.

"People just don't have a clear understanding, so in my opinion the system is driven from a wrong perspective, one that is appropriately looking at dollars and cents--but inappropriately determining where to distribute them.

"Technology has been a very positive factor; but we have not been able to take full advantage of that technology. We see a lot of waste in medicine, and I think that if we were a bit smarter in how to use technology, much of that waste would tend to disappear. I'm talking about all perspectives, from who would administer the care that we provide, how we sometimes repeat a procedure, from an X-ray that gets lost--to always being able to access the film. Technology will allow us to do some of that and help us choose in a more intelligent manner what resources we need to use and how to use them."

Stokosa: "Insurance companies more and more are stepping in between the amputee and the physician and prosthetist. We no longer have the ability to determine what's going to be best for this person; as a function of cost, insurance companies tend to say, If it's going to cost that much, let's go with something cheaper.' The discouraging part is that reimbursement will not meet the very heavy costs and overhead that prosthetists have today. We must have more than just the typical office space; we've got to have machining equipment, many different fabricating materials, plastics fabricating equipment, and tools. All this takes much more space than the typical professional office.

"On the other hand, more and more prosthetists are using central fabrication facilities to do the bulk of their work. I don't do that, but I know many prosthetists do. This is a cost-saving measure to offset the low reimbursement. Typically, when central fabricating services are used, it tends to reduce the ability to customize for each person--there's more of a generalized approach.

"As for the positives, we have a new paradigm emerging in improved surgical techniques--the Ertl procedure--though not as fully recognized and appreciated as it should be. I believe it will be scientifically proven to be superior to conventional techniques we see so commonly today&More and more prosthetists are witnessing the superior benefits of this surgical approach, which in turn increases the quality of life for the amputee and ultimately will reduce medical and rehabilitative costs significantly per patient.

"And we've got better and more interested physicians. I'm finding some younger physicians--both in the physical medicine and rehabilitation areas as well as surgery--who are more interested in providing the best possible care for the amputee and are working together to do the best for the person, where before they could almost care less."

Davidson: "The positive and negative influences in O&P are the same: technology. It is positive in that it's helping people; it's negative in that it is becoming more cost-prohibitive. That's what makes us unique from other industries. For example, when computers or cell phones get better, they become less expensive; but when our components get better, they become more expensive.

"Our ability to provide people with what they need is being strained, definitely. Hopefully, more people will gain access to clinically appropriate devices--and just by numbers, this will lower the expenses of high-end components over time. "

Allen: "The most negative influence on O&P today is the low reimbursement, relative to other segments of healthcare. When you carefully examine the increases in allowable fees for general medical care in the United States for the past 20 years and parallel O&P with it, there is a dismal comparison. O&P has simply not kept up with the inflation of general healthcare. It is simply the result of the national trade association not representing O&P in years past.

"I don't think the changes on the horizon--competitive bidding, fee freezes, and qualified practitioner issues--are favorable, either. I think it will require alterations in the way we provide our expertise and various levels of patient care. The cost of service is becoming more and more critical when you compare expense to the reimbursement. That ratio isn't looking good for the foreseeable future. Although it's going to require more creativity from the business standpoint, I believe that there are other alternatives that will allow us to continue versus compromising the quality of patient care.

"One solution we have been implementing is allowing the majority of our staff to take off Friday afternoons in weekly rotations, as we shrink down to a skeleton crew for that half day--one office staffer, one practitioner, one technician. We have also begun to experiment with staff transitioning to a four-day work week versus a five-day work week. Those are areas where we're looking at making changes, because the historic salary increases we used to see a few years ago are just not possible in today's economic climate."

Judith Philipps Otto is a freelance writer who has also assisted with marketing and public relations for various O&P industry clients. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.